Ch 13: Review Test Flashcards
Procedural, Evaluation and Management
What manual contains codes used in reporting medical services and procedures performed by healthcare providers in the care and treatment of patients?
CPT-4
Who developed CPT codes?
AMA
Who publishes the CPT manual?
AMA
How often is a new CPT manual published?
Annually
When was the first CPT developed and published?
1966
When did the five-digit coding system replace the four-digit system for CPT?
1970
How many sections are in the main body of the CPT manual?
6 sections
The 5-digit CPT codes may be defined further by two additional digits to help explain an unusual circumstance associated with a service or procedure. These two digits are called what?
Modifiers
As with the ICD-10-CM, the CPT index is organized by what?
Main terms
A main term can stand alone, or it can be followed by up to ____ modifying term(s)
Three
To help determine the appropriateness and medical necessity of a service or procedure, a ____ should accompany the claim
Special report
The narrative describing a procedure or service that contains the full description of the procedure without additional explanation is referred to as a(n) ____?
Stand-alone code
Procedures that do not contain the entire written description and refer to the common portion of the procedure listed in the preceding entry are coded with a(n) ____?
Indented code
CPT uses ____ to separate main and subordinate clauses in the code description
A semicolon
The most important thing to remember when using modifiers is that the health record must contain ____ to support the modifier
Adequate documentation
The amount of time the physician spends on bedside care of the hospitalized patient and reviewing the health record and writing orders is called what?
Unit floor time
What is the classification for a patient who is not sick enough to qualify for acute inpatient status but requires hospitalization for a brief time?
Observation status
A procedure by which codes used for data in one database are translated into the codes of another database, allowing information to be shared among databases, is called what?
A crosswalk
HCPCS Level 2 codes are organized into how many sections?
17 sections
If Megan Cartwright was having an excision of an ovarian cyst, the main term would be what?
- Excision
- Cyst
Which codes are designed to classify services provided by a healthcare provider and used primarily in outpatient settings?
E/M
What are three contributing factors that affect the E/M coding level reported?
- Counseling
- Coordination of care
- Nature of presenting problem
What is the AMA’s ongoing effort to improve the structure and processes of CPT codes to reflect today’s coding demands as well as HIPAA challenges?
The CPT-5 project
